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The Blood Standard covers Use of blood and blood products The prescribing practice and clinical use of blood and blood products, and whether or not those products are prescribed and used appropriately Management of blood and blood products Handling, transport, storage (including inventory management) of blood and blood products Administration of blood and blood products The process used to deliver the product to the patient. Scope - activities

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Oversight of the program –Review reports –Identify recurring issues –Root cause analysis of incidents –Develop or agree action plan –Evaluate effectiveness of actions Transfusion governance group (Action 7.4.1) What about in small organisations? Join with other hospitals or identify a group responsible for more than just transfusion practice (ensuring they have a clear remit to govern transfusion practice)

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You should have policies, procedures and protocols that reflect best practice, and national evidence based guidelines where they are available. Your policies, procedures and protocols should cover the spectrum of: –Use of blood and blood products –Management of blood and blood products –Administration of blood and blood products Policies, procedures and protocols (Action 7.1.1)

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Quality improvement cycle Plan Do Check Act Transfusion Quality Improvement System Identify what you will do - develop or identify policies, procedures or protocols Implement the policies Monitor their use AND monitor their quality Take action to improve uptake and improve their quality

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Criterion Two Documenting patient information

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A best possible history of blood product usage and relevant clinical and product information is documented in the patient clinical record This action builds on Action by identifying the information relevant to transfusion of blood and blood products that should be documented The patient clinical record (Action 7.5.1)

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Type of product Volume of product Date and time of commencement Date and time of completion Observations Patient response including any adverse events Product identification Provision of information Patient consent or refusal Indications Special product requirements Known patient transfusion history Compatibility label or report Documentation requirements

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Patient documentation case study What actions are required to demonstrate compliance with the Standard? (note that this case study is presented not to demonstrate particular actions that are required to achieve accreditation, but to demonstrate that the purpose of Standard 7 is to improve safety and quality based on an assessment of risk). Hospital OneHospital Two Has policyYes Documentation completeness audit results 50% of records are complete 95% of records are complete Documentation sample results 5% of units fate not documented <0.01% of units fate not documented

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Transfusion governance group has reviewed findings and developed and implemented an action plan Outcome: the action plan is matched with the level of compliance. Case Study Hospital One Reviewed policy Implemented training of all staff Identified staff associated with non-compliance and communicated directly with them Made changes to the IT system to facilitate inclusion of all information (prompts) Increased frequency of audit on the hospital audit plan Initiated more regular spot checks of fate of product against patient records

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Audit report does not have a management response or action plan They posted on the intranet a reminder to document transfusion in the patient clinical record They have not undertaken any other follow up and the next audit is scheduled for one year away Case Study Hospital One Outcome: the action plan is not matched with the level of compliance. The health service organisation needs to demonstrate additional work prior to accreditation.

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They posted on the intranet a reminder to document transfusion in the patient clinical record They have not undertaken any other follow up and the next audit is scheduled for one year away Outcome: the action plan is matched with the level of compliance. Case Study Hospital Two

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Recognise and respond to adverse events Document adverse events in the patient clinical record Take action to reduce the risk of adverse events as part of your transfusion quality improvement system Managing adverse events

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7.6.1 Patient record Document in patient clinical record External report Report to pathology provider, or product manufacturer Local report Report in local incident system and review by Transfusion Governance Group Executive report Review of incident analysis by highest governance level State report Participate in state haemovigilance reporting National report Participate in national haemovigilance reporting Complexities of incident reporting

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Criterion Three Managing blood and blood product safety

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Blood must be stored and handled appropriately to prevent risk to patients. Systems should be implemented to reduce risks associated with receipt, storage, collection, and transport (Action and 7.7.2) Wastage of blood should be minimised (Action and 7.8.2) Management of blood and blood products

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Many health service organisations receive blood from an outsourced pathology It remains the health service organisation’s responsibility to demonstrate compliance with the Standard Responsibility where services are outsourced You use blood provided by a contracted pathology provider Have a contract that includes standards and reporting Review reports and seek implementation of strategies to rectify problems

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Criterion Four Communicating with patients and carers

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Develop or identify resources to inform patients and their carers about the alternatives, risk and benefits of transfusion (Action 7.9.1) Provide this information to patients and their carers in a format that is understood and meaningful (7.10.1) Allow patients and carers to partner in decisions on their care based on the communication on the alternatives, risks and benefits of transfusion (Action 7.9.2) Communication (Actions 7.9.1, and )

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Have a documented consent policy Ensure written and documented consent meets local policy Ensure the consent is actually informed – link with 7.9 and 7.10 Assess compliance with the consent policy, and take actions to increase compliance Consent (Action )

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When you are developing your consent policy consider…. How long does the consent last? Who is documenting the consent? Is the consent specific to transfusion? What do you do when a patient is unable to consent?